Cardio Pulmonary Interactions during Mechanical Ventilation

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Lecture presented by Dr.Lluis Blanch at Pulmonary Critical Care Egypt, the leading critical care medical event and exhibition organized by the Egyptian College of Critical Care Physicians.www.pccmegypt.com

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Cardio Pulmonary Interactions during Mechanical Ventilation

  1. 1. 22-23 January 2014 Cairo, Egypt Cardio-Pulmonary Interactions during MV Lluis Blanch MD, PhD Senior Critical Care Department Director Research and Innovation Corporació Sanitaria Parc Tauli. Sabadell. Spain. Universitat Autònoma de Barcelona. Spain.
  2. 2. Consequences & ComplicationsConsequences & Complications of Mechanical Ventilationof Mechanical Ventilation •• endotracheal intubationendotracheal intubation •• heartheart--lung interactionlung interaction •• dynamic hyperinflationdynamic hyperinflation •• barotraumabarotrauma •• ventilator induced lung injuryventilator induced lung injury •• difficult patientdifficult patient--ventilator interactionventilator interaction •• infectionsinfections
  3. 3. Intrathoracic pressure is transmitted directly to the heart; all bedside intracardiac pressure measurement represent the sum of intracardiac pressure plus intrathoracic pressure
  4. 4. Heart is surrounded by pericardium and the thorax. Intracardiac pressure measurements therefore are subject to influence of blood volume in the cardiac chambers, the pericardial pressure, and the intrathoracic pressure.
  5. 5. Physiologic principles Intracardiac pressure (mmHg) Hemodynamic monitoring Intrapericardial pressure and intrathoracic are equal and subatmospheric in healty patients (cmH2O) P intracardiac – P intrathoracic = P transmural or distending pressure Preload
  6. 6. P intracardiac – P intrathoracic = P transmural RAP - ∆∆∆∆PPL (Pes) = RAP transmural +5 - (-2) = + 7 mmHg +5 - (+4) = + 1 mmHg cmH2O = 0.74 mmHg
  7. 7. Spontaneous breathing: activation of inspiratory muscles decrease intrathoracic pressure!! VR RA LA Cardiac filling Paradoxic PRA, wedge and PAP This occurs because the inspiratory decrease in the intrathoracic pressure exceeds the inspiratory increase in transmural intracardiac pressures. RA and LA are normally very compliant structures accepting the increased venous return with a minimal increase in transmural pressure.
  8. 8. Sharkey SW. Lippincott- Raven 1997 End-expiration Influence of laboured respiration on wedge pressure waveform
  9. 9. MECHANICAL VENTILATION (MV) CL Ccw CO Emphysema Clung Ccw CO ARDS wL L AWPL CC C PP + ×∆≅∆
  10. 10. Relationship between Venous Return & Cardiac FunctionRelationship between Venous Return & Cardiac Function Effects of Positive Pressure Breaths & Fluid AdministrationEffects of Positive Pressure Breaths & Fluid Administration Miro AM, Pinsky MR. Principles & Practice of MV. 1994.Miro AM, Pinsky MR. Principles & Practice of MV. 1994.
  11. 11. Alveolar vessel: surrounded by alveolar pressure Extraalveolar vessel: surrounded by interstitial pressure (= intrathoracic pressure)
  12. 12. Pepe PE, Marini JJ. Am Rev Respir Dis 1982;126:168.Pepe PE, Marini JJ. Am Rev Respir Dis 1982;126:168. Effect of Discontinuation of MV in a PatientEffect of Discontinuation of MV in a Patient with Severe Airflow Obstructionwith Severe Airflow Obstruction
  13. 13. Apnea during Severe Asthma Relative Lung Volume by Inductive Plethysmography
  14. 14. Rossi A & Ranieri VM. Principles and Practice of MV. Tobin MJ, eRossi A & Ranieri VM. Principles and Practice of MV. Tobin MJ, ed. 1994.d. 1994. Effects Effects of PEEPEffects of PEEP on:on: OxygenationOxygenation Cardiac OutputCardiac Output Oxygen deliveryOxygen delivery PEEPPEEP00 1515
  15. 15. Ppeak & Pplat Overdistension Air Trapping Adverse Physiologic Effects of IRV
  16. 16. Chest 1993;104:871-5 * ** *
  17. 17. AcidosisAcidosis Intracellular Corrected in Hours Renal Compensation 1 – 2 days PulmonaryPulmonary Vasoconstriction & Increase in PVR - Aggravates PHT & Potentiates HPV Increase Intrapulmonary Shunt Laffey JG & Kavanagh BP. Permissive Hypercapnia. In Tobin MJ. Principles & Practice of Mechanical Ventilation. 2006 & 2013. CardiovascularCardiovascular Systemic Vasodilation - Endogenous Catecholamine Production Increase in Cardiac Output Cellular &Cellular & MolecularMolecular Attenuation of Inflammatory Response - Inhibit Release of TNF-ά, IL-1 & IL-8 in Macrophages - Neutrophil Activation - Free Radical Generation & Activity - Regulates Gene Expression: inhibits endotoxin- induced NF-kB activation Physiologic Effects of HypercapniaPhysiologic Effects of Hypercapnia
  18. 18. Crit Care Med 2001;29:1551-5 Individual Predictors of Acute Cor Pulmonale in ARDS n = 75 Mortality 32 % 32 % NS
  19. 19. N Engl J Med 2013;368:806-13. N Engl J Med 2013;368:795-805. Why?: deleterious effects of heavy sedation and NBA, hemodynamic compromise due to adverse effects of high mean airway pressure on the right ventricle, or increased VALI among HFOV non-responders. Durbin CG, Blanch L, Fan E, Hess D. Respir Care 2014 (in press)
  20. 20. PEEP & AutoPEEP in COPD Patients Blanch L, Fernandez R. In: Mancebo J, Brochard L, eds. Arnette 1996; 329-345.
  21. 21. PEEP-Induced Changes in Lung Volume & Cardiac Index in COPD Patients Changes occur only when external PEEP is higher than the critical pressure value: 85% of autoPEEP Ranieri et al ARRD 1993;147:5-13 Baigorri F et al. Crit Care Med 1994;22:1782-91
  22. 22. Heart Lung Interactions duringHeart Lung Interactions during Mechanical VentilationMechanical Ventilation •• Positive pressure ventilation causes:Positive pressure ventilation causes: –– increase in ITP pressureincrease in ITP pressure –– increase in lung volumeincrease in lung volume •• Increase in ITP & lung volume affect:Increase in ITP & lung volume affect: –– heart rateheart rate –– venous returnvenous return –– RV & LV filling and afterloadRV & LV filling and afterload •• Reduced cardiac output by:Reduced cardiac output by: –– increase PVRincrease PVR –– reduced preloadreduced preload –– ventricular interdependenceventricular interdependence –– changes in contractilitychanges in contractility
  23. 23. Tobin M & Jubran A. PPMV 2013 Weaning Failure Patient
  24. 24. Jubran A et al. Am J Respir Crit Care Med 1998; 158:1763.Jubran A et al. Am J Respir Crit Care Med 1998; 158:1763. Pathophysiologic Factors for RespiratoryPathophysiologic Factors for Respiratory Distress during a Weaning TrialDistress during a Weaning Trial Tissue oxygenation: TOTissue oxygenation: TO22 EOEO22 Elevations in right & left ventricular afterload n=11 n=8 ↑SAP ↑PCWP ↓CI
  25. 25. Lemaire F, Teboul JL, et al. Anesthesiology 1988; 69:171. Pathophysiologic Factors for Respiratory Distress during a Weaning Trial Heart & lung interaction: acute LV dysfunction
  26. 26. Pulse Pressure Variation and Frank-Starling Curve Teboul JL, Monnet X. Minerva Anesthesiol 2013;79:398-407
  27. 27. Arterial Pressure in a MV Patient PPV(%)=PPmax-PPmin/[(PPmax+PPmin/2)]x100 Teboul JL, Monnet X. Minerva Anesthesiol 2013;79:398-407
  28. 28. Analysis of ∆Pp is a simple method for predicting and assessing the hemodynamic effects of volume expansion and is a more reliable indicator of fluid responsiveness Am J Respir Crit Care Med. 2000 Jul;162(1):134-8.
  29. 29. PPV in ARDS & Low VT PPV marker of preload responsiveness. PPV > 10-12% still good predictive value. PPV < 10% false negatives may occurs and passive leg raising (PPV↓) or end-expiratory occlusions (PP↑) are needed. Limits: SB, arrhythmias, low lung compliance, right ventricle dysfunction. Teboul JL, Monnet X. Minerva Anesthesiol 2013;79:398-407
  30. 30. MECHANICAL VENTILATION (MV) AFTERLOAD INSPIRATION right V afterload left V afterload Compression of iuxta-alveolar vessels Thoracic- extrathoracic aorta pressure gradient (HYPERINFLATION: asthma, emphysema high PEEP)
  31. 31. Pinsky MR in Principles and Practice of Mechanical Ventilation. Tobin ed McGraw-Hill 1994 In patients with a failing myocardium, CO is relatively insensitive to end diastolic volume changes and is primarily affected by changes in afterload PEEP improve cardiovascular performance LV afterload
  32. 32. CPAP vs O2 IOT < 60% NIV in ACPE Masip J JAMA 2005;294:3124-30 Need to Intubate
  33. 33. CPAP vs O2 Mortality < 47% NIV in ACPE Masip J JAMA 2005;294:3124-30 Mortality
  34. 34. Thank you lblanch@tauli.cat

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